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Hospital at Home: The Evidence Is Not Compelling

Sasha Shepperd, DPhil
[+] Article, Author, and Disclosure Information

From the University of Oxford Headington, Oxford OX3 7LF, United Kingdom.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Sasha Shepperd, DPhil, University of Oxford, Old Road, Headington, Oxford, OX3 7LF, United Kingdom; e-mail, sasha.shepperd@dphpc.ox.ac.uk.

Ann Intern Med. 2005;143(11):840-841. doi:10.7326/0003-4819-143-11-200512060-00015
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Many countries are exploring alternatives to inpatient care because of increasing health care costs, pressure on acute hospital beds, and concern that inpatient care may not produce the best health outcomes for some groups of patients. Developments in medical technology, improvements in housing, and an increasing emphasis on primary care have all encouraged innovations that reduce reliance on inpatient care (12). Hospital at home provides health care for patients who would otherwise require a hospital stay. Patients may use hospital at home after early discharge from the hospital or directly after assessment in the emergency department or in a physician's office. Hospital at home comes in several flavors, which vary according to the admission criteria, utilization of technology, organizational structure, and funding arrangements.

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Hospital in the Home and prevention of delirium
Posted on December 6, 2005
Gideon A Caplan
Prince of Wales Hospital
Conflict of Interest: None Declared

Dear Editor,

The article by Leff is a vitally important confirmation of the phenomenon that treatment at home prevents delirium.

We have also recently published on-line further evidence of this in a randomised controlled trial (RCT) of older patients, after acute hospitalisation, having rehabilitation at home versus institutional rehabilitation. We found that the rehabilitation at home group had reduced odds of developing delirium [ Odds Ratio = 0.17; 95% Confidence Interval 0.03-0.065] and also rehabilitated faster at home [Duration of rehabilitation 15.97 v 23.09 days; p=0.0164](1)

Delirium is the proverbial "canary in the coalmine" of aged care, a transient early warning signifiying increased incidence of mortality, nursing home placement and impaired physical and cognitive function. However, due to the proportionally greater incidence of delirium, detection of a significant change in the other outcomes requires a study with much greater power.

Unfortunately, the recent Cochrane Review of Hospital at Home includes many studies which were essentially failed experiments, because there was no substitution of in-hospital days with hospital in the home, only add-on care. Where health outcomes were measured, these were often done long after the hospitalisation, when the symptoms of delirium would have generally settled, if they were looked for.(2)

Whilst Shepperd has criticised the large number of eligible patients who did not participate(3), in our experience, it is not surprisingly, often (exceedingly) difficult to convince patients to enter trials of different health services, particularly when their site of care will be determined by random selection. This does not reflect in any way on the viability of those services once they are established. Our Hospital in the Home RCT recruited one patient a fortnight, but now looks after 20 patients every day.

We believe it is also erroneous to criticise the Leff study as being provider-specific in economic terms. The extent of cost saving, which has been found in similar trials which substitute Hospital in the Home care for in-patient care,(4) but not in trials where the hospital at home was essentially an add-on service(5) demonstrates the importance of service design.

The ramifications of delirium prevention demonstrated by Leff et al, make the case urgent for a multicentre randomised controlled trial of Hospital at Home adequately powered to detect changes in mortality and nursing home placement.

1. Caplan GA, Coconis J, Board N, Sayers A, Woods J. Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial). Age and Ageing advance access http://ageing.oxfordjournals.org/cgi/reprint/afi206?ijkey=jJbDXpaoiGJvmfw&keytype=ref

2. Shepperd S, Illiffe S. Hospital at home versus inpatient hospital care [Review]. The Cochrane Database of Sytematic Reviews. 2005.

3. Shepperd S. Hospital at home: the evidence is not compelling. (Editorial) Annals of Internal Medicine 2005; 143: 840-1.

4. Board N, Brennan N, Caplan GA. A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Australian and New Zealand Journal of Public Health 2000; 24(3):305-311.

5. Shepperd S, Harwood D, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home care with inpatient care. II: cost minimisation analysis. British Medical Journal 1998; 316: 1802-6.

Conflict of Interest:

None declared

Editorial criticises zebra for not being a horse
Posted on December 19, 2005
Michael Montalto
Royal Melbourne Hospital
Conflict of Interest: None Declared

To The Editor

Shepperd (1) is incorrect to dismiss the paper by Leff et al(2).

The definitions for Hospital in the Home vary widely. This variation extends from post-acute discharge community programs that tenuously argue their status as Hospital in the Home through possible prevention of readmission (common in British studies) through to integrated hospital clinical units that deliver acute hospital technology and skills to patients who would otherwise require a traditional bed to receive this service.

Shepperd, while aware of differences, is not willing to make distinctions. Self definition as Hospital in the Home seems to be good enough. Studies cited in the editorial, including that of post discharge care of heart failure and long term palliative care, do not hold any relevance to the effectiveness of Hospital in the Home. I don't believe this taxonomic laxity would be tolerated in other interventions.

Leff has placed his trial within the strict substitution definition of Hospital in the Home. The evidence for the acuity of this study population, and for the hospital level nature of the intervention, is strong.

Unlike most reported Hospital in the Home studies, he details the intervention carefully (on page 800). Unlike Shepperd, I am not aware of 22 RCTs that have conducted an intervention as described.

On this basis, Leff makes a significant, even compelling, contribution to the evidence for Hospital in the Home care. This is the first multi-centre randomised study of a genuine hospital in the home intervention that substitutes entirely for hospital type care. In this context, the outcomes demand a more positive response than that offered by Shepperd.

The establishment of Hospital in the Home units purely for the purposes of research will always struggle to achieve satisfactory participation rates. Hospital in the Home requires serious financial and organisational commitment by hospital providers, genuine long term clinical leadership and staffing, integration and good relationships with referring clinicians, and a variety of other complex inputs to compose a successful, innovative service. Even with those inputs, Hospital in the Home can face challenges from entrenched hospital attitudes, and reluctant funders. Those inputs are difficult to bring to maturity in a trial setting, due to time and financial restrictions, and patients and referrers will sense this. Of course, once those inputs are mature, providers of Hospital in the Home and their patients will not tolerate deliberate halving of throughput. This is an issue for many other health service interventions.

Finally, Annals has done these authors a disservice. This editorial appears to be a dissenting review dressed up for publication. If the paper was as insignificant as the editorial suggests, why publish it?

Dr. Michael Montalto MB BS PhD Director, Hospital in the Home Epworth Hospital and Royal Melbourne Hospital c/ Epworth Hospital 89 Bridge Rd Richmond AUSTRALIA 3121 Email: michael.montalto@epworth.org.au


1. Shepperd S "˜Hospital at Home:the evidence is not compelling' Ann Int Med 2005: 143: 840 -841

2. Leff B, Burton L, Mader S, et al "˜Hospital at Home: feasibility and outcomes of a program to provide hospital level care at home to acutely ill older patients' Ann Int Med 2005: 143: 798-808

Conflict of Interest:

None declared

Hospital-at-home for patients referred to internal medicine wards
Posted on January 11, 2006
Brigitte Santos-Eggimann
Institute of Social and Preventive Medicine, University of Lausanne (Switzerland)
Conflict of Interest: None Declared

In the midst of published randomised controlled trials whose authors, too frequently, neglected to report on the fraction of patients actually transferred to hospital-at-home, the editorial by Shepperd (1), following the article by Leff et al (2), offers an accurate view regarding the economics of hospital-at-home as an alternative to inpatient care in internal medicine wards of acute care hospitals.

Leff et al selected pathologies that account for a large proportion of the casemix in internal medicine departments. Over 3 sites, in 11 months, they transferred 84 patients in hospital-at-home, 8.5% of all patients referred for the selected conditions. The hospital-at-home model had been preceded by a pilot phase and the low proportion of inclusions was not explained by study constraints, since only 4.6% patients refused the data collection. Overall, 22% were considered as eligible from a medical point of view. The difficulty of home transfers in the night and refusals further reduced the proportion of transfers.

We obtained similar results in Switzerland for pneumonia and heart failure patients referred to acute care hospitals (3). Over 3 sites, we registered 301 heart failure and 441 pneumonia patients in 9 months; 28% of heart failure and 38% of pneumonia patients were medically eligible for transfer to hospital-at-home care, immediately or after stabilization. Finally, 4% of heart failure and 10% of pneumonia patients received hospital-at-home care. The experience was a pilot, patients may have been reluctant to accept an innovation, but the team was very motivated to enrol patients in hospital-at-home. We must admit that, for many old patients really needing the type of acute care usually provided in the hospital, the social environment is just insufficient for delivering it within the frame of hospital-at-home.

Inclusion in the analyses of organizational costs for a 3 sites hospital-at-home scheme totalling 84 admissions over 11 months might change the conclusion. The question, for heart failure and pneumonia patients, is whether better outcomes justify investments in programs that do not divert a substantial proportion of cases from hospital beds. In our Swiss experience, hospital-at-home was subsequently opened to other pathologies. It was considered as an interesting approach particularly for palliative care and for chemotherapies. Evaluations of hospital-at-home for palliative care should not be mixed with evaluations of hospital-at- home for heart failure. The article by Jeff et al provides useful data for decision-makers who envisage, on economic grounds, hospital-at-home for patients referred to internal medicine wards.


1. Shepperd S. Hospital at home: the evidence is not compelling. Ann Int Med 2005;143:840-841

2. Leff B, Burton l, Mader S, et al. Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Int Med 2005;143:798-808

3. Santos-Eggimann B, Chavaz N, Larequi T, Lamy O, Yersin B. Heart failure and community-acquired pneumonia: cases for home hospital? Int J Qual Health Care 2001;13:301-307.

Conflict of Interest:

None declared

A brief response
Posted on January 26, 2006
Sasha Shepperd
University of Oxford
Conflict of Interest: None Declared

To the Editor

A brief response to Dr Montalto

1. The example of discharge planning for patients with heart failure was used in the editorial "˜Hospital at home: the evidence is not compelling' to illustrate one of the many types of intervention that are being developed to reduce reliance on inpatient care "“ not as an example of hospital at home.(1)

2. Montalto described the example I provided of hospital at home for patients requiring terminal care as 'long term palliative care' - it was not. The intervention was designed for people requiring terminal care with the aim of 'substituting' for hospital care and the eligibility criteria required patients to have a prognosis of a life expectancy of less than 6 months.(2) This study was published in 1992; the study met the inclusion criteria of the Cochrane systematic review as an intervention substituting for in patient hospital care, and it was a randomized comparison.

3.In the Cochrane systematic review hospital at home is defined as "˜a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period.'(3) Hospital at home was defined at the protocol stage of the systematic review, and this definition was applied by 2 independent reviewers to select trials for inclusion in the review [see Cochrane Methods http://www.cochrane.dk/cochrane/handbook/hbook.htm], this resulted in 22 randomised controlled trials of hospital at home being included in the review. The trials are categorized within the review according to type of intervention: early discharge to hospital at home of elderly medical patients, early discharge of patients following elective surgery, admission avoidance schemes and those providing care for patients with a terminal illness.

4.Montalto claims that the study by Leff and colleagues(4) is a multi centre randomized study "“ it is not. Yes it was multi centre, but no one was randomised.

Sasha Shepperd D.Phil DH Research Scientist in Evidence Synthesis, Department of Public Health, University of Oxford, Rosemary Rue Building, Headington Oxford OX3 7LF

Reference List

1. Shepperd S. Hospital at home: the evidence is not compelling. Annals of Internal Medicine 2005;143:840-1.

2.Hughes SL, Cummings J, Weaver F, Manheim L, Braun B, Conrad K. A randomized trial of the cost effectiveness of VA hospital- based home care for the terminally ill. Health Serv.Res. 1992;26:801-17.

3. Shepperd S,.Iliffe S. Hospital at home versus in-patient hospital care [Review]. The Cochrane Database of Systematic Reviews 2005.

4. Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK et al. Hospital at home: feasibility and outcomes of a program to provide hospital level care at home for acutely ill older people. Annals of Internal Medicine 2005;143:798-808.

Conflict of Interest:

None declared

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